Basic Information
| Provider Information | |||||||||
| NPI: | 1316213846 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KING | ||||||||
| FirstName: | TIFFANY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2810 COLISEUM CENTRE DR STE 520 | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282173252 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9807851113 | ||||||||
| FaxNumber: | 9807851114 | ||||||||
| Practice Location | |||||||||
| Address1: | 855 BRADLEY ST | ||||||||
| Address2: | |||||||||
| City: | CONCORD | ||||||||
| State: | NC | ||||||||
| PostalCode: | 280252979 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9807851113 | ||||||||
| FaxNumber: | 9807851114 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/29/2012 | ||||||||
| LastUpdateDate: | 06/09/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/09/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106S00000X | N | 222Q00000X | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Developmental Therapist | 103K00000X | 1-22-58825 | NC | Y | Behavioral Health & Social Service Providers | Behavioral Analyst |
No ID Information.